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Radiodiagnosis Radiodiagnosis of dontogenous of dontogenous tumours and tumours and non tumoral formations of jawsnon tumoral formations of jaws. . Radio Radio
diagnosis of diagnosis of nonon n dontogenous dontogenous benign andbenign and malignant malignant tumours and non tumoral tumours and non tumoral
formations of jawsformations of jaws..
Prof. G.S. Moroz, MDProf. G.S. Moroz, MD
Department of Oncology & Department of Oncology & Radiology,Radiology,
Ternopil State Medical UniversityTernopil State Medical University
Carotid Body Tumor*Note: The pictures don't correspond with the text of the slides
EtiologyRare neoplasm arising from nonchromaffin paraganglia in
carotid artery bifurcation
Heredofamilial (autosomal-dominant) form can occur (in less
than 10%) Can be multiple,
bilateral, or multicentric
Clinical Presentation
Typically presents as a mass in the lateral neck
May be associated with bruit, hoarseness, dysphagia
Diagnosis
Ultrasonography as a screening measure • Angiography of both carotid systems
Differential Diagnosis
Metastatic tumor • Vagal nerve sheath tumor
Treatment
Surgical removal • Radiation therapy • Combined surgical and radiotherapy
Prognosis
Generally good • Can be locally invasive • May
metastasize in 5 to 25% of cases
Exostosis Etiology
Unknown • Probable reactive Phenomenon (stimulus undetermined)
Clinical Presentation
Asymptomatic, bony, nodular masses • Cortical bone enlargement of the jaws;
usually bilateral and symmetric • Usually multiple; slow growing • Most commonly along buccal/facial
aspects of the maxillary and mandibular alveolar ridge • Overlying mucosa intact, unremarkable • Usually develops in adults
Diagnosis
May appear Radiographicall
y as
homogeneous opacities
Differential Diagnosis
Peripheral fibroma • Periostitis • Periosteal/ parosteal osteosarcoma
Treatment
None required • May need to be removed for prosthesis (denture) construction
Prognosis
Excellent
Benign Nonodontogenic Benign Nonodontogenic TumorsTumors
Juvenile Ossifying FibromaEtiology
A rapidly evolving
variant of ossifying fibroma of the young • Cause
unknown
Clinical Presentation
Onset between 5 and 15 years of age
• Rapid growth over several weeks
• Maxilla and paranasal areas predominate
• Tooth displacement common
Radiographic Findings
Well-defined radiolucency • Focal mineralization may be
noted. • Adjacent bone may be eroded
or destroyed.
Microscopic Findings
Prominent stromal cellularity • Woven bone and/or
psammomatous calcifications • Plump osteoblast rimming
Diagnosis
Correlation of histologic and radiographic findings
Differential Diagnosis
Osteosarcoma • Central giant cell granuloma • Odontogenic tumor
Treatment
Wide local excision or resection •
Reconstruction
Prognosis
Recurrence rate
of 30 to 50%
Langerhans Cell Disease(Idiopathic Histiocytosis)
Etiology • Unknown • Proliferation of Langerhans’
cells (immune surveillance cells) normally found in skin, mucosa,
bone marrow, and lymph nodes
Clinical Presentation
A broad spectrum, typically divided into three subsets, as follows:
• Unifocal or multifocal chronic disease of bone (eosinophilic granuloma) • Widely disseminated chronic disease of bone and soft tissue (Hand-Schüller-Christian disease) • Acute, disseminated disease with bone marrow involvement (Letterer-Siwe disease) • Most arise in childhood; eosinophilic granuloma often arises
in adolescents and adults. • Jaw lesions noted in up to 20% of cases with tenderness,
loose teeth (focal to segmental), gingival inflammation, and friability
Radiographic Findings
Bone lesions often punched out, sharply circumscribed
• “Floating teeth” appearance with alveolar bone involvement
• Skeletal survey should be performed to rule out multiple bone
involvement
Diagnosis
Radiographic demonstration of lytic bony lesions • Infiltrate of mononuclear cells, often with clefted
nuclei • Often accompanied by a variety of other cell types,
including eosinophils, lymphocytes, giant cells, plasma cells • Immunohistochemical demonstration of CD1a
staining • Langerhans’ cells also stain for S-100 protein,
although the antibody is less specific. • Ultrastructural demonstration of cytoplasmic
racquet-shaped Birbeck granules
Differential Diagnosis: Radiologic
Juvenile periodontitis, endocrinopathies, hypophosphatasia,
leukemia, bony malignancy (primary/metastatic)
• In adults: myeloma
Treatment
Localized variant • Surgical curettage of bony lesions • Low-dose radiation therapy of
inaccessible lesions • Widespread variants • Chemotherapy including
methotrexate, vincristine, cyclophosphamide • Bone marrow transplantation for
resistant/recurrent disease
Prognosis
Varies with form of disease, as follows: • Localized variant: very good • Disseminated variant: fair to poor
Ossifying Fibroma
Etiology • A benign
fibro- osseous lesion of bone • Cause
unknown
Clinical Presentation
Expansile lesion of bone • Cortices intact • May produce deformity,
malocclusion, dysfunction • Mandibular lesions are more
common than are maxillary.
Radiographic Findings
Well-delineated, smooth contours • Quality varies from lucent to
opaque • Margins may be sclerotic. • Can resorb roots and displace
teeth • May displace mandibular canal
Microscopic Findings
Fibrovascular stroma • Islands/trabeculae of osteoid,
woven bone • Cementum droplets may be
present.
Diagnosis
Correlation of histologic and radiographic findings
Differential Diagnosis: Radiographic
Odontogenic cyst
• Giant cell lesion
• Odontogenic tumor
Differential Diagnosis: Histologic
Fibrous dysplasia
(must have clinical-
pathologic correlation)
Treatment
Conservative excision • Enucleation with peripheral bony curettage
Prognosis
Excellent
Osteoma
Etiology • Sporadic form is idiopathic • May be a component of
Gardner’s syndrome • Excludes maxillary and
mandibular tori
Clinical Presentation
Sporadic form with frontal and sphenoid sites predisposed
• May be multiple • Solitary lesions rare in jaws
Radiographic Findings
Well circumscribed,
dense, sclerotic • May be subperiosteal or medullary
Diagnosis
Radiographic features • Microscopic features:
normal cortical and trabecular bone
Differential Diagnosis
Tori, exostoses • Ossifying fibroma • Osteoblastoma • Focal
sclerosing osteitis
Treatment
Usually none • Local
resection, if
compromising
Prognosis
Excellent • Little recurrence potential • When associated with Gardner’s
syndrome, malignant conversion of intestinal polyps is assured.
Peripheral Ossifying Fibroma
Etiology • A reactive hyperplasia of the
gingiva; may be related to chronic irritation • Periodontal ligament/membrane
origin postulated
Clinical Presentation
Exclusive gingival location; commonly interdental
• Nodular, sessile to pedunculated, usually ulcerated mass
• Slow growing; may rarely displace teeth • Usually in young adults and adolescents • Early lesions may bleed easily. • Anterior maxillary arch is favored site
Diagnosis
Central islands or trabeculae of bone/cementum
• Fibroblastic proliferation in a sheet-like configuration
• Usually ulcerated with granulation tissue base
Differential Diagnosis
Pyogenic granuloma • Peripheral giant cell granuloma • Peripheral fibroma • Peripheral odontogenic tumor • Osteosarcoma/chondrosarcoma • Metastatic neoplasm
Treatment
Excision including
underlying periosteum or associated periodontal ligament
Prognosis
Recurrence occasionally
seen; believed to be related to incomplete excision
Benign Nonodontogenic TumorsBenign Nonodontogenic Tumors
Benign Nonodontogenic TumorsBenign Nonodontogenic Tumors
Malignant NonodontogenicTumors Ewing’s Sarcoma Etiology • Unknown • Chromosomal translocations t(11;22),
t(7;22), t(7;21) noted • Gene rearrangement often noted, that is,
(22;q12) and expression of the MIC2 gene • Genetically related to primitive peripheral
neuroectodermal tumor via translocations
Clinical Presentation
60% in males; over 95% in those under 20 years of age
• Chiefly in bone and soft tissues • Highly malignant • Pain, numbness, and swelling often early complaints • Diffuse, irregular, lytic bone lesion • Cortical expansion variable • Second most common bone tumor of
children/adolescents • Soft tissues of head and neck account for 11% of
extraskeletal sites
Diagnosis
Radiographs often show “moth-eaten” appearance and laminar periosteal bone reaction • Cortex may be eroded or expanded
Differential Diagnosis
Osteosarcoma • Lymphoma • Peripheral neuroectodermal
tumor of bone • Primitive rhabdomyosarcoma • Neuroectodermal tumor of
infancy
Treatment
Radiation and multiagent chemotherapy
Prognosis
54 to 74% 5-year survival rate in localized osseous form • Late relapse
not uncommon
Metastatic Cancer
Etiology • Spread of a primary malignancy
to the oral cavity structures or jaws (usually from lung, breast,
prostate, colon, kidney) • Accounts for < 1% of oral
malignancies
Clinical Presentation
Usually manifests in the jaws with pain and swelling
• Not uncommon is loosening of teeth or pathologic jaw fracture
• Soft tissue location is rare. • Most frequent sites of primary
neoplasms are kidney, lung, breast, colon, prostate, stomach • Intraosseous lesions with lytic, ill-
defined radiolucencies
Microscopic Findings
As with the primary tumor • Tumor marker studies
(immunohistochemical) may be necessary
to define the site of origin.
Diagnosis
Radiographic findings • Biopsy
Differential Diagnosis
Primary soft tissue tumor • Primary osseous tumor • Periodontitis (localized) •
Osteoradionecrosis
Treatment
Local radiation • Combination chemoradiother
apy
Prognosis
Poor
Malignant Nonodontogenic Malignant Nonodontogenic TumorsTumors
OsteosarcomaEtiology
May be associated with pre-existing bone disease such as the
following: • Paget’s disease (10 to 15%) • Fibrous dysplasia (0.5%) • Mutation/amplification of p53, c-
myc, c-JUN, c-fos, MOM2, CDK4, SAS
Clinical Presentation
May present with pain paresthesia, trismus, nasal or paranasal
sinus obstruction • May masquerade as an odontogenic
infection • Intraoral signs are as follows: • Tooth mobility (vertical) • Periapical radiolucency (teeth vital) • Distal displacement of terminal molar • Jaw mass may be ulcerat
Radiographic Findings
Early intraoral findings • Displacement of teeth • Root resorption • Absent or attenuated lamina dura • Uniformly widened periodontal membrane space • Later jaw bone findings • Lytic, “moth-eaten” destruction • Cortical destruction • Soft tissue extension • Erosion of mandibular canal • 25% of cases have “sunburst effect” (radiating
radiopaque spicules)
Microscopic Findings
Sarcomatous stroma • Osteoid production by neoplastic
cells • Four basic patterns (no
prognostic significance) are as follows:
• Osteoblastic • Fibroblastic • Chondroblastic • Telangiectatic
Diagnosis
Correlation of clinical, radiographic, Pathologic findings
Differential Diagnosis
Fibro-osseous lesion • Osteomyelitis •
Osteoradionecrosis • Metastatic tumor • Other form of sarcoma
Treatment
Radical ablative surgery • Hemimandibulectomy • Partial maxillectomy ± orbital
exenteration • Adjuvant
chemotherapy/radiotherapy
Prognosis
Survival ranges from 12 to 58% at 5 years
• Mandibular lesions are associated with a greater survival rate
than are maxillary lesions.
Odontogenic Tumors Odontogenic Tumors Adenomatoid Odontogenic
Tumor
Etiology • Derivation from epithelial
component of the enamel organ • Represents less than 10% of
odontogenic tumors • Biologic behavior allows for
distinction from ameloblastoma
Clinical Presentation
Narrow age range, 5 to 30 years, with most cases noted during
second decade • Female predilection • Anterior jaw location common • Association with unerupted tooth • Asymptomatic; occasionally produces
expansion of alveolar bone • Rarely occurs in gingival soft tissue
(peripheral) • May produce root divergence of adjacent teeth
Radiographic Findings
Well defined, unilocular, often adjacent to crown of unerupted
tooth • Opaque foci may be scattered
within the lucency in a “snowflake” or “salt and pepper”
pattern.
Microscopic Findings
Characteristic intraluminal/intracystic growth with welldefined
capsule • Dual cell population: spindle cells
and cuboidal to columnar cells forming tubules or pseudoducts • Foci of dystrophic calcification or
eosinophilic droplets may be noted.
Diagnosis
Radiographic features • Microscopic findings
Differential Diagnosis
Dentigerous cyst • Odontogenic keratocyst • Calcifying odontogenic cyst • Lateral root cyst • Calcifying epithelial
odontogenic tumor
Treatment
Enucleation
Prognosis
No recurrence
Ameloblastic Fibroma andAmeloblastic Fibro-odontoma Etiology • Ameloblastic fibroma: a benign mixed
odontogenic tumor with concomitant epithelial and
mesenchymal neoplastic proliferation • Ameloblastic fibro-odontoma: as for
ameloblastic fibroma with the addition of an odontoma • Spontaneous; no known cause for
either
Clinical Presentation
Noted mostly in first and second decades
• Approximately 70% in mandible, usually posterior region
• No gender predilection • May cause jaw expansion • Asymptomatic
Radiographic Findings
Well defined with hyperostotic margin
• Unilocular to multilocular • Often associated with an
unerupted tooth • Ameloblastic fibro-odontoma has
opaque component(s) related to enamel and dentin in the
odontoma component
Diagnosis
Lobulated, cellular mesenchymal component with proliferating
odontogenic epithelium in cords and islands
• Enamel matrix, dentin formation associated with odontoma
(when present)
Differential Diagnosis
Ameloblastoma • Dentigerous cyst • Odontogenic keratocyst • Odontogenic myxoma • Central giant cell granuloma
Treatment
Conservative surgical
excision/ curettage
Prognosis
Excellent
Ameloblastoma
Etiology • A benign, aggressive jaw tumor
of odontogenic epithelial (ectodermal)
origin; the most common odontogenic tumor after the
odontoma • Incidence of 0.3 cases per million
people
Clinical Presentation
Peak incidence during third to fifth decades • 80% occur in the mandible, chiefly in molar
and ramus region • Often presents in association with
unerupted third molar teeth • May produce marked deformity, facial
asymmetry • Extraosseous or peripheral variant arises in
gingival tissues of older adults (fifth to seventh decades) • Typically slow growing, but persistent
Radiographic Findings
Osteolytic or radiolucent with sclerotic, smooth, even borders
• May be unilocular to multilocular • Root resorption or tooth
displacement may be seen. • Can expand affected jaw in any
plane • Cortical perforation may occur.
Diagnosis
Sheets, strands, islands of odontogenic epithelium • Peripheral layer of cuboidal to columnar ameloblast-like
cells enclosing a cell population analogous to stellate reticulum
of the enamel organ • Cystic degeneration common within stellate reticulum
component • Several histologic patterns described have no clinical
relevance. • A biologic variant, cystic (unicystic) ameloblastoma,
occurs in younger patients; has a less aggressive clinical course and
is managed more conservatively • Malignant variants rarely seen
Differential Diagnosis
Dentigerous cyst • Odontogenic keratocyst Odontogenic myxoma • Central giant cell granuloma
Treatment
Varies with subtype, size, location • Solid/multicystic lesions
generally require local excision or resection. • The cystic variant requires local
excision, as recurrences may follow curettage only
Prognosis
Generally good; recurrence rates higher with conservative
treatment • Recurrence rates of up to 15%
following marginal resection • Very good prognosis for cystic
ameloblastoma • Long-term follow-up necessary
Calcifying Epithelial Odontogenic Tumor
Etiology • A benign odontogenic tumor of
uncertain histogenesis • Stratum intermedium
component of enamel organ is favored
cell of origin
Clinical Presentation
Chiefly in posterior mandible • Painless, slow growing • Mean age of occurrence is
approximately 40 years • Occasional soft tissue origin
(peripheral) noted as a sessile gingival mass • Jaw expansion a common clinical
presentation
Radiographic Findings
Usually noted in association with an impacted tooth
• Multilocular; most often with mixed radiolucent and
radiopaque features • Impacted tooth often obscured by
tumor-associated calcification • Margins may be well defined or
sclerotic and vague.
Diagnosis
Radiographic features • Biopsy findings of polyhedral
epithelial cells, nuclear pleomorphism,
amyloid material, and concentric calcifications with
epithelial islands
Differential Diagnosis
When radiolucency predominates: dentigerous cyst, odontogenic
keratocyst, ameloblastoma, odontogenic myxoma
• With mixed radiolucent and radiopaque features: calcifying
odontogenic cyst, adenomatoid odontogenic tumor, ameloblastic
fibro-odontoma, fibro-osseous lesion, osteoblastoma
Treatment
Local, conservative excision including a thin rim of normal
bone (so-called ostectomy) versus conservative en bloc removal
• Peripheral lesions with a narrow periphery of normal-appearing
mucosa
Prognosis
Very good • Recurrence rate is low, from 10 to 15% • Long-term follow-up recommended
Odontogenic Myxoma
Etiology • A benign odontogenic tumor • Unknown origin
Clinical Presentation
A lesion of adulthood (average occurrence at 30 years)
• Equal male:female and mandible:maxilla occurrences
• Wide age range: second through sixth decades
• Usually asymptomatic • May produce jaw expansion
Radiographic Findings
Well-defined, unilocular to multilocular radiolucency
• Loculi range from small “honeycomb” to large “soap bubble”
shapes • Cortical thinning may be present with
larger lesions. • Perforation of the cortex is
uncommon.
Microscopic Findings
Minimal cellularity, myxoid background
• Variable amounts of collagen • Scattered residual bony
trabeculae • Odontogenic epithelial rests are
rarely noted.
Diagnosis
Radiographic features • Microscopic findings
Differential Diagnosis
Other odontogenic tumor: ameloblastoma
• Odontogenic cysts: odontogenic keratocyst, dentigerous cyst,
glandular odontogenic cyst • Central giant cell granuloma
Treatment
Excision with bony curettage • Large lesions may require en bloc resection.
Prognosis
Good • Can be aggressive rarely • Recurrences not uncommon,
secondary to gelatinous quality and lack of capsule
Odontoma
Etiology • A hamartomatous or benign
mixed odontogenic tumor of the jaw
• Composed of enamel, dentin, cementum, and pulp tissue
Clinical Presentation
Two forms, as follows: • Complex: a randomly arrayed mixture of dental
tissues with no gross resemblance to a tooth • Compound: multiple, tooth-like structures • Mean age of occurrence, 12 to 16 years • Asymptomatic, usually small and discovered
incidentally • Jaw expansion may be present with large lesions. • Presence may be heralded by an over-retained
primary tooth or by alveolar swelling.
Radiographic Findings
Well-localized, mixed radiolucent and radiopaque lesion
• Within alveolar segment of jaws • Complex form most commonly noted
in mandibular molar area • Compound form favors anterior jaw
region, usually the maxilla; may contain a few small teeth or large
numbers of tiny tooth-like structures
Diagnosis
Radiographic presentation • Histologic demonstration of dental hard tissues
Differential Diagnosis
Ameloblastic fibro-odontoma • Adenomatoid odontogenic
tumor • Calcifying odontogenic cyst • Focal sclerosing osteitis,
osteoma
Treatment
Conservative excision/ curettage
Prognosis
Excellent
Peripheral Odontogenic Fibroma
Etiology • A benign Proliferation neoplasm of fibroblastic and odontogenic epithelial origin
Clinical Presentation
Asymptomatic, firm, slow-growing mass of the attached gingiva
• Overlying mucosa unremarkable and intact • Sessile growth pattern • Usually along facial or buccal aspect of
gingiva • Calcifications may be present
radiographically. • Underlying alveolar bone is spared. • Uncommon to rare • Also seen centrally (within bone)
Diagnosis
Fibrous to myxoid stromal tissue • Scattered islands and strands of
odontogenic epithelium • Some cells may be vacuolated. • The degree of epithelial
proliferation may vary from minimal
to prominent.
Differential Diagnosis
Peripheral giant cell granuloma • Pyogenic granuloma • Peripheral fibroma • Peripheral ameloblastoma
Treatment
Excision: local and
conservative
Prognosis
Excellent
Odontogenic TumorsOdontogenic Tumors